Bonaventure of Salmon Creek.

STATE OF WASHINGTON DEPARTMENT OF SOCIAL AND HEALTH SERVICES Aging and Long-Term Support Administration PO Box 45600, Olympia, WA 98504-5600 January 21, 2025 ELECTRONIC-FACSIMILE Administrator Bonaventure of Salmon Creek c/o 3425 Boone Rd SE, Salem, OR 97317 Assisted Living Facility License # 2321 Licensee: Bonaventure of Salmon Creek LLC IMPOSITION OF CIVIL FINES Dear Administrator: On January 9, 2025, the Department of Social and Health Services (DSHS), Residential Care Services completed a follow-up visit at your facility. This letter constitutes formal notice of civil fines on the license for your assisted living facility, also known as Bonaventure of Salmon Creek, located at 13700 NE Salmon Creek Ave, Vancouver, by the State of Washington, Department of Social and Health Services. These actions are taken under the authority granted pursuant to Laws of 1998, Chapter 272 and RCW 18.20.190. The civil fines on the license are based on the following violation of the RCW and/or WAC as described in the attached Statement of Deficiencies (SOD) report dated January 9, 2025. Civil Fines WAC 388-78A-2474(1)(a)(b)(c)(d)(4) Training and home care aide $300.00 certification requirements. The licensee failed to ensure three staff had completed or had documentation of the required training to work as a long-term care worker in assisted living facilities or received their required health care aide (HCA) certification within the required 200 days. These failures placed all residents at risk for harm due to staff not being properly trained. This is an uncorrected deficiency previously cited on November 7, 2024. Administrator Bonaventure of Salmon Creek License # 2321 January 21, 2025 Page 2 WAC 388-78A-2462(2)(a)(b) Background checks—Who is $300.00 required to have. The licensee failed to complete or document a Washington state name and date of birth background check for one staff member. This failure placed all residents at risk for harm by employing staff with a possible disqualifying criminal conviction(s) or pending charge(s) for a disqualifying crime(s). This is an uncorrected deficiency previously cited on November 7, 2024. WAC 388-78A-2140(1)(a)(i)(ii)(iii)(b)(c)(d)(e) Negotiated service $300.00 agreement contents. The licensee failed to document in the resident’s Negotiated Service Agreements (NSA) the plan to provide specific resident identified care and service needs for three residents. Failure to document a complete NSA placed these residents at risk for unmet care needs and for care and services not being provided per the NSA. This is an uncorrected deficiency previously cited on November 7, 2024. WAC 388-78A-2150(1) Signing negotiated service agreement. $300.00 The licensee failed to ensure the Negotiated Service Agreement (NSA) was agreed to and signed by the resident or the responsible party at least annually for three residents. This failure placed these residents and their responsible party at risk for not being involved in their care decisions and the services being provided. This is an uncorrected deficiency previously cited on November 7, 2024. WAC 388-78A-2390(1)(2) Resident records. $300.00 The licensee failed to maintain a current characteristic roster accurately documenting resident care needs and services for two residents. This failure placed these residents at risk for proper care needs not being met. This is an uncorrected deficiency previously cited on November 7, 2024. WAC 388-78A-2480(1) Tuberculosis—Testing—Required. $300.00 The licensee failed to complete tuberculosis (TB) (an infectious bacterial disease that often attacks the lungs) testing within three days of hire for one staff. This failure placed all staff and residents at risk for possible exposure and harm from a communicable disease. This is an uncorrected deficiency previously cited on November 7, 2024. Administrator Bonaventure of Salmon Creek License # 2321 January 21, 2025 Page 3 WAC 388-78A-2665(1)(2)(3)(4)(5)(6) Resident rights—Notice—Policy $300.00 on accepting medicaid as a payment source. The licensee failed to ensure a Medicaid policy was on a page separate from other documents and was signed on or before admission for one resident. This failure placed this resident at risk of not being aware of their rights as they pertain to Medicaid. This is an uncorrected deficiency previously cited on November 7, 2024. NOTE: These are the violations, which resulted in the fines; see the attached Statement of Deficiencies for any additional violations. Attestation (Plan of Correction): Return the enclosed SOD within 10 calendar days with the following: • The date you have or will have each deficiency corrected; • A signature and date attesting that you are taking actions to correct and maintain correction for each cited deficiency. Return the signed and dated SOD to: Michael Burdick, Field Manager Region 3, Unit I 800 NE 136th Ave Suite 220 Vancouver, WA 98684 Phone: (360) 450-1218/ Fax: (360) 992-7969 rcsregion3email@dshs.wa.gov Appeal Rights: You have two appeal rights: Informal Dispute Resolution (IDR) and an Administrative Hearing. Each has a different request timeline. Informal Dispute Resolution [RCW 18.20.195] You have an opportunity to challenge the deficiencies and/or enforcement actions through the state's IDR process. All IDR requests must be in writing and include: • The deficiencies you are disputing; and • The method of review you prefer (face-to-face, telephone conference or documentation review). The written request must be received by the 10th working day from receipt of this letter. Administrator Bonaventure of Salmon Creek License # 2321 January 21, 2025 Page 4 During the IDR process, you will have the opportunity to present written and/or oral evidence to dispute the deficiencies. Send your written request to: Informal Dispute Resolution Program Manager Residential Care Services PO Box 45600 Olympia, Washington 98504-5600 Formal Administrative Hearing You may contest the civil fines by requesting a formal administrative hearing to challenge the deficiency, which resulted in the civil fines. All hearing requests must be in writing and include: • A copy of this letter; and • A copy of the Statement of Deficiencies. The written request must be received within twenty-eight (28) calendar days of receipt of this letter. Send your written request to: Office of Administrative Hearings PO Box 42489 Olympia, Washington 98504-2489 Payment: If you do not request a formal administrative hearing, the civil fines are due to the Office of Financial Recovery twenty-eight (28) calendar days after receipt of this letter. Mail a check for $2,100.00 payable to the ‘Department of Social and Health Services’, and if you have or have had a Medicaid resident(s), please include your ProviderOne ID Number # on the check, to: DSHS Office of Financial Recovery PO Box 9501 Olympia, WA 98507-9501 (360) 664-5919 / FAX: (360) 664-8401 OFRMMISVendor@dshs.wa.gov If the Office of Financial Recovery has not received your payment within twenty-eight (28) days after receipt of this letter, interest will begin to accrue immediately on the balance, at the Administrator Bonaventure of Salmon Creek License # 2321 January 21, 2025 Page 5 rate of one percent per month. If you do not submit a hearing request or make payment within twenty-eight (28) days, the balance due will be recovered. If you have any questions, please contact Michael Burdick, Field Manager, at (360) 450-1218. Sincerely, Matt Hauser Compliance Specialist Residential Care Services Enclosure cc: Field Manager, Region 3, Unit I RCS Regional Administrator, Region 3 HCS Regional Administrator, Region 3 DDA Regional Administrator, Region 3 WA LTC Ombuds Office of Financial Recovery, Vendor Program Unit HQ Central Files DRW HP

This document was prepared by Residential Care Services for the Locator website. Residential Care Services Investigation Summary Report Provider/Facility: Bonaventure of Salmon Provider Type: Assisted Living Facility Creek License/Cert.#: 2321 Intake ID: 147867 Compliance Determination #: 48102 Region/Unit #: RCS Region 3 / Unit I Investigator: Yvonne Chitekwe Investigation Date(s): 10/01/2024 through 11/18/2024 Complainant Contact Date(s): Allegation(s): 1.Nursing service: Facility reported inappropriate administration of antipsychotic medication as ordered by the Doctor. 2. Quality of care/treatment: Facility reported failure to administer antipsychotic medication as ordered by the Doctor. Investigation Methods: Sample: Total residents: 63 Resident sample size: 3 Closed records sample size: 0 Observations: Staff to resident interactions Resident to resident interactions Medication administration Identified resident Residents Activities Interviews: Identified resident Identified staff Residents Family members Record Reviews: Medical records Incident investigation Facility policies Investigation Summary: 1.Nursing service: The on-site investigation was conducted in relation to all allegations and incidents identified in the intake. Based on interviews, observations and records review, no failed facility practice in the nursing services when resident's medications were wrongly administered was substantiated during the investigation. 2. Quality of care/treatment: The on-site investigation was conducted in relation to all allegations and incidents identified in the intake. Based on interviews, This document was prepared by Residential Care Services for the Locator website. observations and records review, a failed facility practice to administered resident's medication as they were ordered by their doctor was substantiated during the investigation. Conclusion / Action: Failed Provider Practice Identified / Citation(s) Written Failed Provider Practice Not Identified / No Citation Written N/A This document was prepared by Residential Care Services for the Locator website. This document was prepared by Residential Care Services for the Locator website. This document was prepared by Residential Care Services for the Locator website.

STATE OF WASHINGTON DEPARTMENT OF SOCIAL AND HEALTH SERVICES Aging and Long-Term Support Administration PO Box 45600, Olympia, WA 98504-5600 September 27, 2024 ELECTRONIC-FACSIMILE Administrator Bonaventure of Salmon Creek c/o 3425 Boone Rd SE Salem, OR 97317 Assisted Living Facility License # 2321 Licensee: Bonaventure of Salmon Creek LLC LIFT CONDITIONS ON A LICENSE Dear Administrator: This letter is formal notice that the conditions placed on your license on December 29, 2022, in a notice letter dated December 29, 2022, are lifted effective March 10, 2023. If you have any questions, please call Michael Burdick, Field Manager, at (360) 450-1218. Sincerely, Matt Hauser Compliance Specialist Residential Care Services cc: Field Manager, Region 3, Unit I RCS Regional Administrator, Region 3 HCS Regional Administrator, Region 3 DDA Regional Administrator, Region 3 WA LTC Ombuds HQ Central Files DRW HP

STATE OF WASHINGTON DEPARTMENT OF SOCIAL AND HEALTH SERVICES Aging and Long-Term Support Administration PO Box 45600, Olympia, WA 98504-5600 November 21, 2024 ELECTRONIC-FACSIMILE Administrator Bonaventure of Salmon Creek c/o 3425 Boone Rd SE Salem, WA 97317 Assisted Living Facility License # 2321 Licensee: Bonaventure of Salmon Creek LLC IMPOSITION OF CIVIL FINE Dear Administrator: On November 7, 2024, the Department of Social and Health Services (DSHS), Residential Care Services completed a Full Inspection visit at your facility. This letter constitutes formal notice of a civil fine on the license for your assisted living facility, also known as Bonaventure of Salmon Creek, located at 13700 NE Salmon Creek Ave, Vancouver, by the State of Washington, Department of Social and Health Services. These actions are taken under the authority granted pursuant to Laws of 1998, Chapter 272 and RCW 18.20.190. The civil fine on the license is based on the following violation of the RCW and/or WAC as described in the attached Statement of Deficiencies (SOD) report dated November 7, 2024. Civil Fine WAC 388-78A-2240 Nonavailability of medications. $1,000.00 The licensee failed to obtain prescribed medications in a correct and timely manner for three residents. This failure placed these residents at risk of harm from adverse reactions due to medications not being given as prescribed. This is a recurring deficiency previously cited on September 20, 2022, December 14, 2022, and January 3, 2024. NOTE: This is the violation, which resulted in the fine; see the attached Statement of Deficiencies for any additional violations. Administrator Bonaventure of Salmon Creek License # 2321 November 21, 2024 Page 2 Attestation (Plan of Correction): Return the enclosed SOD within 10 calendar days with the following: • The date you have or will have each deficiency corrected. • A signature and date attesting that you are taking actions to correct and maintain correction for each cited deficiency. Return the signed and dated SOD to: Michael Burdick, Field Manager Region 3, Unit I 800 NE 136th Ave Suite 220 Vancouver, WA 98684 Phone: (360) 450-1218/ Fax: (360) 992-7969 rcsregion3email@dshs.wa.gov Appeal Rights: You have two appeal rights: Informal Dispute Resolution (IDR) and an Administrative Hearing. Each has a different request timeline. Informal Dispute Resolution [RCW 18.20.195] You have an opportunity to challenge the deficiencies and/or enforcement actions through the state's IDR process. All IDR requests must be in writing and include: • The deficiencies you are disputing; and • The method of review you prefer (face-to-face, telephone conference or documentation review). The written request must be received by the 10th working day from receipt of this letter. During the IDR process, you will have the opportunity to present written and/or oral evidence to dispute the deficiencies. Send your written request to: Informal Dispute Resolution Program Manager Residential Care Services PO Box 45600 Olympia, Washington 98504-5600 Administrator Bonaventure of Salmon Creek License # 2321 November 21, 2024 Page 3 Formal Administrative Hearing You may contest the civil fine by requesting a formal administrative hearing to challenge the deficiency, which resulted in the civil fine. All hearing requests must be in writing and include: • A copy of this letter; and • A copy of the Statement of Deficiencies. The written request must be received within twenty-eight (28) calendar days of receipt of this letter. Send your written request to: Office of Administrative Hearings PO Box 42489 Olympia, Washington 98504-2489 Payment: If you do not request a formal administrative hearing, the civil fine is due to the Office of Financial Recovery twenty-eight (28) calendar days after receipt of this letter. Mail a check for $1,000.00 payable to the ‘Department of Social and Health Services’, and if you have or have had a Medicaid resident(s), please include your ProviderOne ID Number # on the check, to: DSHS Office of Financial Recovery PO Box 9501 Olympia, WA 98507-9501 (360) 664-5919 / FAX: (360) 664-8401 OFRMMISVendor@dshs.wa.gov If the Office of Financial Recovery has not received your payment within twenty-eight (28) days after receipt of this letter, interest will begin to accrue immediately on the balance, at the rate of one percent per month. If you do not submit a hearing request or make payment within twenty-eight (28) days, the balance due will be recovered. Administrator Bonaventure of Salmon Creek License # 2321 November 21, 2024 Page 4 If you have any questions, please contact Michael Burdick, Field Manager, at (360) 450-1218. Sincerely, Matt Hauser Compliance Specialist Residential Care Services Enclosure cc: Field Manager, Region 3, Unit I RCS Regional Administrator, Region 3 HCS Regional Administrator, Region 3 DDA Regional Administrator, Region 3 WA LTC Ombuds Office of Financial Recovery, Vendor Program Unit HQ Central Files DRW SN

STATE OF WASHINGTON DEPARTMENT OF SOCIAL AND HEALTH SERVICES Aging and Long-Term Support Administration PO Box 45600, Olympia, WA 98504-5600 April 29, 2024 ELECTRONIC-FACSIMILE Administrator Bonaventure of Salmon Creek c/o 3425 Boone Rd SE Salem, OR 97317 Assisted Living Facility License #2321 Licensee: Bonaventure of Salmon Creek LLC IMPOSITION OF A CIVIL FINE Dear Administrator: On April 18, 2024, the Department of Social and Health Services (DSHS), Residential Care Services completed a compliant investigation at your facility. This letter constitutes formal notice of a civil fine on the license for your assisted living facility, also known as Bonaventure of Salmon Creek, located at 13700 NE Salmon Creek Ave, Vancouver, by the State of Washington, Department of Social and Health Services. These actions are taken under the authority granted pursuant to Laws of 1998, Chapter 272 and RCW 18.20.190. The civil fine on the license is based on the following violation of the RCW and/or WAC as described in the attached Statement of Deficiencies (SOD) report dated April 18, 2024. Civil Fine WAC 388-78A-2210 (2)(a)(b) Medication services. $400.00 The licensee failed to ensure residents received medications as prescribed for two residents reviewed for medication service. This failure resulted in one resident not receiving medication as ordered for 5 days and one resident not receiving medication for 11 days and placed them at risk for medical complications. This is a recurring deficiency previously cited on January 27, 2023. NOTE: This is the violation, which resulted in the fine; see the attached Statement of Deficiencies for any additional violations. Administrator Bonaventure of Salmon Creek License #2321 April 29, 2024 Page 2 Attestation (Plan of Correction): Return the enclosed SOD within 10 calendar days with the following: • The date you have or will have each deficiency corrected; • A signature and date attesting that you are taking actions to correct and maintain correction for each cited deficiency. Return the signed and dated SOD to: Michael Burdick, Field Manager Region 3, Unit I 800 NE 136th Ave Suite 220 Vancouver, WA 98684 Phone: (360) 450-1218/ Fax: (360) 992-7969 rcsregion3email@dshs.wa.gov Appeal Rights: You have two appeal rights: Informal Dispute Resolution (IDR) and an Administrative Hearing. Each has a different request timeline. Informal Dispute Resolution [RCW 18.20.195] You have an opportunity to challenge the deficiencies and/or enforcement actions through the state's IDR process. All IDR requests must be in writing and include: • The deficiencies you are disputing; and • The method of review you prefer (face-to-face, telephone conference or documentation review). The written request must be received by the 10th working day from receipt of this letter. During the IDR process, you will have the opportunity to present written and/or oral evidence to dispute the deficiencies. Send your written request to: Informal Dispute Resolution Program Manager Residential Care Services PO Box 45600 Olympia, Washington 98504-5600 Administrator Bonaventure of Salmon Creek License #2321 April 29, 2024 Page 3 Formal Administrative Hearing You may contest the civil fine by requesting a formal administrative hearing to challenge the deficiency, which resulted in the civil fine. All hearing requests must be in writing and include: • A copy of this letter; and • A copy of the Statement of Deficiencies. The written request must be received within twenty-eight (28) calendar days of receipt of this letter. Send your written request to: Office of Administrative Hearings PO Box 42489 Olympia, Washington 98504-2489 Payment: If you do not request a formal administrative hearing, the civil fine is due to the Office of Financial Recovery twenty-eight (28) calendar days after receipt of this letter. Mail a check for $400.00 payable to the ‘Department of Social and Health Services’, and if you have or have had a Medicaid resident(s), please include your ProviderOne ID Number # on the check, to: DSHS Office of Financial Recovery PO Box 9501 Olympia, WA 98507-9501 (360) 664-5919 / FAX: (360) 664-8401 OFRMMISVendor@dshs.wa.gov If the Office of Financial Recovery has not received your payment within twenty-eight (28) days after receipt of this letter, interest will begin to accrue immediately on the balance, at the rate of one percent per month. If you do not submit a hearing request or make payment within twenty-eight (28) days, the balance due will be recovered. Administrator Bonaventure of Salmon Creek License #2321 April 29, 2024 Page 4 If you have any questions, please contact Michael Burdick, Field Manager, at (360) 450-1218. Sincerely, Matt Hauser Compliance Specialist Residential Care Services Enclosure cc: Field Manager, Region 3 Unit I RCS Regional Administrator, Region 3 HCS Regional Administrator, Region 3 DDA Regional Administrator, Region 3 WA LTC Ombuds Office of Financial Recovery, Vendor Program Unit HQ Central Files DRW JB

This document was prepared by Residential Care Services for the Locator website. This document was prepared by Residential Care Services for the Locator website. This document was prepared by Residential Care Services for the Locator website. This document was prepared by Residential Care Services for the Locator website. This document was prepared by Residential Care Services for the Locator website. This document was prepared by Residential Care Services for the Locator website.